10. CLAIM PROVISIONS expedited external grievances, the independent review organization shall notify you and us of the determination made within 72 hours after the external grievance is filed. Such determination is binding on us. You shall not pay any of the costs associated with the services of an independent review organization. Should you submit information to us that is relevant to the resolution of the appeal of the grievance, and was not previously considered or reviewed by us: · We may reconsider the prior resolution. If we elect to reconsider, the independent review organization shall cease the external review process until the reconsideration is completed. · We shall notify you of a decision within 72 hours after the information is submitted, for a reconsideration, if making a decision in the standard timeline would seriously jeopardize the Insured’s life or health, or his or her ability to reach and maintain maximum function. · Under any other circumstances, we shall notify you within 15 days after the information is submitted. · If you do not agree with our decision, you may request that the independent review organization resume the external review process. · If we choose to not reconsider our initial resolution after receipt of the relevant new information, we shall forward such submitted information to the independent review organization not more than 2 business days after we receive it. Documents and other information created or received by the independent review organization or the medical review professional in connection with an external grievance review are not considered public records to which access is granted and will be treated in accordance with confidentiality requirements of state and federal law. · An independent review organization is immune from civil liability for actions taken in good faith in connection with an external review and its work product and/or determination are admissible in a judicial or administrative proceeding. However, the work product and/or determination do not, without other supporting evidence, satisfy a party’s burden of proof or persuasion concerning any material issue of fact or law. If you have the right to an external review of a grievance under Medicare, you may not request an external review of the same grievance under this process. Pursuing a resolution through the grievance process does not add to or otherwise change the terms of coverage included in this Policy. For further information, you may contact us at the phone number or address listed on the front cover of this Certificate. To whom are benefits payable? We will pay you all benefits, if your Proof of claim is satisfactory to us, except in the following situations: · you are a minor. In such case, claim may be made by your duly appointed guardian, conservator or committee and we will pay to such person or persons; · due to physical or mental incapacity, you cannot, in our judgment, give us a valid receipt for payments. In such case, claim may be made as described above; or · you die before we pay you. In such case, claim may be made by your executor or the administrator of your estate and we will pay to such person or persons. If we do not pay you and claim is not made by the appropriate person designated above, we may, at our option, make payments under either or both Methods A or B below. Any decision to pay any benefits, prior to the appointment of the appropriate person designated (as shown above), is solely at our discretion, and we may choose to pay no amounts under any circumstances until such appropriate person is formally appointed. Method A: We may pay up to the sum of $5,000 to any individual or entity that has provided Proof of having incurred or paid expenses as a result of funeral services provided to or on your behalf. If we pay such a benefit, we will not have to pay that benefit amount again and the total benefit due under the Policy shall be reduced by the amount paid under this provision. Method B: We may pay the whole or any part of such benefit: 16-SD-C-01 Page32